Understanding Your Patients: Cultural Competency Can Make the Difference


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Cover Story - March 2006  


By  Erin Prather
Associate Editor  

A woman who had recently immigrated from Asia underwent a mammogram in The University of Texas M.D Anderson Cancer Center mobile van in Houston. The screening detected a problem, and the woman became upset when told of the findings.

"She believed she didn't have breast cancer before entering the van," said Beverly J. Gor, EdD, program coordinator for the cancer center's minority health research center. "Now she had it and was convinced the screening was the cancer's cause instead of recognizing that the problem had been found early and could be treated."

Dr. Gor, who works with Houston's rapidly growing Asian-American population, says a "physician must understand where his or her patients are coming from in order for a treatment plan to be successful. The woman in the mammography program may not have come back for treatment had her fears about how she contracted breast cancer not been addressed."

If doctors don't understand, she added, they "might ask the patient to do things he or she doesn't understand or that counter his or her already held beliefs about health. As a result, the patient may ignore a treatment plan or not come back for a follow-up. It's not that the physician has a bad patient, but that there is a lack of understanding. The mammography patient's misperception could have further compromised her health, especially if she had chosen to not follow up with a physician out of fear that treatment would cause more cancer," Dr. Gor said.

Cultural competency is one of those terms that can make you roll your eyes. Ethnic differences and their impact on behavior is a complex subject many folks often simply do not understand or are afraid to explore, fearing they will be accused of insensitivity or worse. Yet Texas physicians, facing increasingly diverse patients as heretofore minority populations become the majority, need to take cultural differences in account to help address mounting concerns over racial and ethnic disparities in health care.

But dealing with a patient whose beliefs may be radically different from yours or your other patients' doesn't have to be impossible. For Paul Haidet, MD, MPH, assistant professor at Baylor College of Medicine, cultural competency is rooted in one word: communication.  

"The issue at hand is how we as individuals understand one another and one another's perspective of things," said Dr. Haidet, a staff physician at the Michael E. DeBakey VA Medical Center inHouston. " The key task for physicians is to establish a form of connection with their patients during the 15 or so minutes they meet with them. During that interaction, the physician is the driver of the communication. I try to demonstrate to the patients that I understand what issues are important to them because any treatment plan will be influenced by those issues," he said.   

The Dec. 1, 2005, issue of the American Family Physician  says efforts directed toward more culturally relevant health care enrich the patient-physician relationship and improve patient rapport, adherence, and outcomes.

Unfortunately, a study in the Sept. 7, 2005, Journal of the American Medical Association ( JAMA ) found that resident physicians say their preparedness for delivering cross-cultural care lags well behind their preparation in other clinical and technical areas.

The report explained that although residents perceived cross-cultural care to be important, little clinical time was allocated during residency to address cultural issues, and they received little training, formal evaluation, or role modeling. The report called for significant improvements in cross-cultural education to help eliminate racial and ethnic disparities in health care.


The Issue of Understanding  

Richard Paul Bartlett, MD, who has served as chief of staff at the local hospital in the West Texas town of Crane, is very aware of how cultural differences can contribute to health barriers. A member of the statewide Health Disparities Task Force, Dr. Bartlett is a minority Anglo in a mostly Hispanic community. Although fluent in Spanish, he says being culturally competent is much more than simply knowing a language.

"Cultural competency is understanding where a person is coming from. It means treating patients and their families with dignity and respecting their culture; these things need to be an effort that is made and not just assumed. Physicians and their staff need to make a constant effort to learn the diverse needs of the populations they are serving."

The June 10, 1998, JAMA says physicians must be aware of the cultural and psychological biases of their patients and address them in culturally sensitive ways. Using breast cancer as its example, the report said physicians will more effectively promote behavior that may allow early detection and treatment if they understand their patients' fears and misconceptions about the disease.

The April 2003 issue of the American Journal of Preventive Medicine concurs with Dr. Gor. It says the quality of health care can be compromised when a patient does not understand what the doctor is telling him, the doctor does not speak the patient's language, or the doctor is insensitive to cultural differences.

Adds Dr. Gor, who also is part of the task force, "Physicians can look at the census to understand who is in their communities. They can see what language groups are out there, which might lead them to a nonprofit or community-based organization that can assist them with communication needs. Health care professionals and their staff should understand the demographics of the communities they serve and be willing to make some modifications to improve health care for the whole community."

Austin internist Abraham Delgado, MD, medical director for TMF Health Quality Institute, believes physicians should not only be aware of the cultural differences among their patients, they also should consider their own backgrounds and the perceptions they bring to the health care setting.

"There is a culture of medicine that people are introduced to when they train in health care. Physicians, nurses, and other health care professionals learn a way of looking at the world that is part of their training. It is an influence. For example, this country has a very high-tech view of medicine; technology is part of the culture. At some point, physicians will find themselves trying to bring the benefits of this technological culture to patients who may not be familiar with that particular view of treatment."

Armin D. Weinberg, PhD, director of the Baylor College of Medicine Chronic Disease Prevention and Control Research Center, says it is a mistake to assume that cultural competency is relevant only to race or ethnicity. Physicians also should take into consideration such cultural concerns as literacy, language, economics, and geography, he says.

While culture competency programs such as those offered by the TMF Health Quality Institute and American Academy of Family Physicians (see " The Road to Cultural Competency ") can be valuable, Dan Bustillos, JD, PhD, a health disparities fellow at Baylor, warns that cultural competency cannot be taught in just an afternoon lecture.

"There is growing concern that cross-cultural competency is now being seen as only a skill set, that a good practitioner will simply master it. But just because you memorize that a person from a particular background will act a certain way does not guarantee he or she will do so. It's important that physicians remember that each of their patients is different culturally, just as they are medically."

Jacquelyn Johnson-Minter, MD, MPH, a TMF clinical advocate and physician consultant for tuberculosis clinics inHarrisCounty, agrees. "As physicians, we learn there is no 100 percent in medicine because we are all different. Even if I've read all the literature that said 99 percent of these patients will prefer this, I may have the 1 percent in front of me who doesn't. Yes, they are part of a larger group, but how they interact in a health care setting or in a crisis may be very different than what you might expect."   

A Simple Question  

Dr. Haidet practices what he preaches in communicating with his patients by asking them one simple question. Their response may alter how he implements a treatment plan.

"I ask my patients, 'What do you think is going on?' or 'What's worrying you most about this?' I always take the extra 20 seconds to ask that sort of question. Often the diagnosis stays the same, but how we set up the treatment plan and how I present future information can change because of that answer."

He says many times the patient says "something that I never would have anticipated. Patients come from all walks of life. And they come from all sorts of backgrounds. And these backgrounds set up their expectations for an illness and how they can treat it. There is no way to screen for that, the only thing you can do is take the moment to say, 'Tell me your understanding of what is going on here.'"

The American Family Physician report suggests physicians use body language and speak slowly and directly to the patient, using short sentences and a normal tone of voice. It says patients, often feeling embarrassed, might nod their head in agreement even if they don't comprehend what the physician is saying.

"I convey to my patients that we are a team trying to solve a health problem," Dr. Johnson-Minter said. "Showing patients that you are concerned about understanding them and about being understood is the key. Physicians cannot be afraid to admit they did not understand a patient the first time around. A solution can materialize if both parties are working toward it."

Dr. Gor says interpreters are invaluable and acknowledges that physicians often feel most overwhelmed by language barriers. She advises them to acknowledge a patient's culture, then to assess how well they are communicating with the patient. If they cannot cross the language barrier, she suggests exploring community resources.

"Some communities are fairly well organized and have organizations or religious centers that can provide health translators," Dr. Delgado said. "For years, physicians have relied on family members, especially children, for translation. But it's been shown that children may not be the best translators. In many cultures, having children know a lot about their elders can be considered very inappropriate. A child might be uncomfortable discussing certain medical conditions. You can have a less than ideal, sometimes very unsatisfactory, interaction if you rely on them." 

Dr. Bustillos says even having a translator present does not guarantee smooth communication. He points out that although a translator may be fluent in Spanish, it could be Mexican-based Spanish, which will sound quite different to someone from Spain or Cuba. Although someone may speak another's language, it is not a guarantee they know anything about that person's culture.

"An optimal situation is to have a trained medical translator, a trained culture broker, a person that deals with these sorts of interactions on a daily basis. What cultural competency should be at its core is awareness that differences exist, the awareness that there is a potential for misunderstanding in a dialogue, then from there we should try to overcome these misunderstandings by using whatever means are available to us," he said.

Dr. Delgado reiterates that developing trust, communication, and understanding between people makes a difference in patient care. He believes physicians who are culturally educated about their patients provide better treatment.

"Communication can decrease the risk of malpractice. It improves medical care and decreases the chance that medical errors will be made. One can definitely make a medical case for the importance of cultural competency."

Erin Prather   can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629.  



The Road to Cultural Competency

To train physicians to care for diverse populations, the U.S. Department of Health and Human Services Office of Minority Health commissioned the Cultural Competency Curriculum Modules. The modules are grounded on principles outlined in the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care and are a first step in giving health care professionals training in cultural competency.

Although CLAS standards are primarily directed at health care organizations, physicians and other health care professionals are encouraged to use them to make their practices more culturally and linguistically accessible.

The TMF Health Quality Institute is promoting the modules, which offer Texas primary care physicians the opportunity to earn up to 9 free continuing medical education hours. Primary care practices that participate in the project also can receive consultation to implement CLAS standards and a 3-percent (up to $1,000) premium reduction from Texas Medical Liability Trust. Physicians and other health professionals can sign up for free online at  www.tmf.org/9CME  or by calling call TMF at (866) 439-8863.

Another resource is the Intercultural Cancer Council's pocket guide, " Cultural Competence in Cancer Care: A Health Care Professional's Passport." It helps health care professionals better assess, diagnose, and treat cancer patients of various cultural backgrounds. Call (713) 798-4617 or log on to  iccnetwork.org .

The American Academy of Family Physicians (AAFP) offers a cultural competency program as well, which includes handbooks to address the importance of cultural competence in health care delivery. For more information, contact Kaiser Permanente at (510) 271-6663 or log on to the AAFP Web site at  www.aafp.org/x13787.xml .

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Interpreters Required

Physicians who receive financial reimbursement under Medicaid or Medicare must comply with a federal law that requires them to notify patients who speak limited English about their right to language-assistance services and, if needed, provide interpreters at no cost to the patient.

For more information, log on to the Texas Health and Human Services Commission Civil Rights Office Web site at www.hhs.state.tx.us/aboutHHS/CivilRights.shtml  or call (888) 388-6332. 



How to Improve Your Cultural Competency

  • Do not necessarily treat the patient the same way you would want to be treated. Culture determines the roles for polite, caring behavior and will formulate the patient's concept of a satisfactory relationship.
  • Begin by being more formal with patients born in another culture. In most countries, a greater distance between caregiver and patient is maintained through the relationship. Except when treating children or very young adults, it is best to use the patient's last name when addressing him or her.
  • Do not be insulted if the patient does not look you in the eye or ask questions. In many cultures, it is disrespectful to look directly at another person (especially one in authority) or to make someone "lose face" by asking him or her questions.
  • Do not make assumptions about the patient's ideas about how to maintain health, the cause of illness, or the means to prevent or cure it. Adopt a line of questioning that helps determine some of the patient's central beliefs about health, illness, and illness prevention. Allow the patient to be open and honest.
  • Do not discount beliefs not held by Western biomedicine. Often, patients are afraid to tell Western caregivers they are visiting a folk healer or taking an alternative medicine because they have been ridiculed in the past.
  • Do not discount how beliefs in the supernatural may affect the patient's health. If the patient believes the illness has been caused by embrujado (bewitchment), the evil eye, or punishment, he or she is not likely to take any responsibility for the treatment. Belief in the supernatural may result in the patient's failure to either follow medical advice or comply with the treatment plan.
  • Inquire indirectly about the patient's belief in the supernatural or use of nontraditional cures. Say something like, "Many of my patients from _____ believe, do, or visit ______. Do you?"
  • Try to ascertain the value of involving the entire family in the treatment. In many cultures, medical decisions are made by the immediate or extended family. If the family can be involved, the patient will more likely comply with the treatment.
  • Whenever possible, incorporate into the treatment plan the patient's folk medication and folk beliefs that are not contradicted. This will help the patient develop trust in the treatment and help assure that the treatment plan is followed.

Available on the American Medical Student Association Web site at  www.amsa.org/programs/gpit/cultural.cfm .  



Tips for Small Practices

An April 2005 Commonwealth Fund field report surveyed health care practices to assess how physicians adapt their practices to treat patients with limited English proficiency. Eleven site visits and seven phone interviews took place at health care settings with 10 or fewer clinicians. Promising initiatives used by the physicians include the following.

Language Access Planning
Small practices are developing written language plans, as suggested by the U.S. Department of Health and Human Services. These plans identify language needs and propose strategies for meeting those needs. Physicians are monitoring patient satisfaction as they continue to evaluate and expand their language services. This may be as simple as patient-charting notations or more formal patient surveys.

Bilingual Midlevel Practitioners
A limited supply of bilingual physicians, along with heavy competition to hire them, has motivated some practices to focus on recruiting and hiring bilingual midlevel staff who perform multiple roles, including language-assistance tasks. For example, persons with conversational proficiency in a second language may provide services at the front desk (e.g., answering phones and scheduling appointments), while those with medical proficiency may interpret for patients during medical or clinical visits.

Particularly in communities with heavy demand for services in a particular language, physicians may hire full- or part-time on-site interpreters. Physicians may also consider interpreters who are available to work on contract. Potential sources for hiring such interpreters include area hospitals, state or local agencies, refugee resettlement sites, community-based organizations, or commercial entities. Physicians are increasingly taking steps to improve the competency of bilingual staff who interpret for patients. On-the-job training is offered in some practices by bilingual midlevel practitioners and office administrators, who also may assess language skills during the hiring process and evaluate new staff in training. A growing number of practices are seeking to minimize their reliance on family or friends of patients as interpreters. Where family members are still being used, some physicians attempt to have a trained interpreter sit in during the medical encounter or follow up with the family within 24 hours to verify the patient's condition.

Telephone Language Lines
Some practices are developing ways to make interpreters via telephone accessible to both physicians and patients. Some practices have placed speaker phones in examination rooms. Some physicians carry cell phones with speakers that can be easily exchanged between doctor and patient.

Written Translations
When evaluating the need for translated materials, many practices make extensive use of existing materials. They use translated materials offered by various organizations, Web-based materials from federal and state governments, and materials downloaded from health departments in other countries such as Taiwan. Some practices also use bilingual staff, contract interpreters, local hospitals, and faith-based organizations to translate documents.

Funding Opportunities
Many small practices seek funding from various sources, including federal, state, and local governments; foundations; and nonprofit organizations.



Case Studies in Cultural Competency

Reevaluating Ethics and Values From a Different Cultural Perspective
An adolescent, unmarried girl in Saudi Arabia was taken to a hospital for an unrelated spinal problem when her American doctors discovered that she was pregnant. Two of the doctors, familiar with the gender expectations of young women, knew that the pregnancy would bring great dishonor to the family and that punishment could bring death to the girl. They arranged for her to have an abortion in a neighboring country. They told her parents that treatment for the spinal problem was only available in this other country.

A third doctor, who had been in Saudi Arabia only a short time, felt that he could not be a part of this deception. The other two doctors urgently convinced the third doctor that the girl would be in serious danger if her pregnancy was revealed to her family. The third doctor reluctantly agreed to say nothing.

At the last minute, as the girl started to board the plane, the doctor uncontrollably felt he could not go through with what he felt was an ethical violation of truth-telling and told the father the girl was pregnant. The father immediately grabbed the girl and left with her. Several weeks later, the third doctor ran into the girl's brother and asked about her condition. The boy shook his head and explained that the girl was dead. The family's honor had been restored. The distraught doctor left Saudi Arabia.

  • What were the conflicting values about which the three physicians disagreed?
  • Did the third doctor make a mistake by telling the family or did he just do what he felt was ethically imperative?
  • How might reexamining his ethics have helped the doctor make a better decision?
  • As the physician, what would you have done? How would you justify your actions?

Source:   Galanti GA.  Caring for Patients From Different Cultures: Case Studies From American Hospitals. 2nd ed.Philadelphia,Pa:UniversityofPhiladelphiaPress; 1997.  

Family Relationships, Truth-Telling
Mrs. Lee was a 49-year-old Cantonese-speaking woman who had immigrated years ago from China to the United States. She lived with her husband and youngest son, Arnold, age 22. Studies revealed that Mrs. Lee suffered from lung cancer that had metastasized to her lymph nodes and adrenal glands. Arnold did not want Mrs. Lee's diagnosis known to her. Eventually, the cancer spread to her brain.

Her physician, knowing her poor prognosis, suggested a DNR to her son, who refused to even discuss the possibility with his mother. Arnold felt his role as son and family member meant he must protect his mother from "bad news" and loss of hope. He believed telling her the dim prognosis would be cruel and cause unnecessary stress. Though futile, the son insisted that all heroic methods be used, including a ventilator, to save his mother's life. He accused the house staff and physician of racism and threatened litigation. As a family member, he considered himself, not the doctors or patient, responsible for his mother's treatment.

  • Had you been the physician, what would you have done?
  • Try to see Arnold's point of view. What might he have been thinking?
  • How did cultural differences in the telling of bad news, treatment limits, and the role of family differ between provider and patient?
  • How did Mrs. Lee's age and her son's sense of responsibility to the family affect her care?
  • What might have been some culturally competent options for the house staff?
  • How do the ethics of "informed consent" and autonomy fit into the beliefs of Mrs. Lee and her family?

Source: Muller JH, Desmond BD. Cross-cultural medicine - a decade later: ethical dilemmas in a cross-cultural context - a Chinese example. West J Med . 1992;157(3):323-327.  

Conflicts About Disability, Right to Refuse Treatment
A Hmong child was born with a clubfoot. Doctors felt the foot would cause social embarrassment and make walking difficult. They recommended an operation to reshape the foot. The family believed the foot was a blessing, a reward for ancestral hardships.

Because the family believed "fixing" the foot would bring shame and punishment to the family and Hmong community, they refused treatment. The family went to the Supreme Court to defend their right to refuse treatment. They won.

  • What do you think should have happened in the court case? Why?
  • In this case, the operation did not involve life or death. But what if it had?

Source: Harry B.  Developing Cultural Self-Awareness . In: CASAnet Library: Cultural Competency. Available at:  www.casanet.org/library/culture/culture-aware.htm .  

These case studies are available on the American Medical Student Association Web site at  www.amsa.org/programs/gpit/cultural.cfm .  


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